Parent Questionnaire

If you would prefer to complete a hard copy of this form, please click here, print the form and return to:

PARENT QUESTIONNAIRE

Child's Full Name (required)
Address (Street No., Street Name, Suburb)
Email (required)
Postcode
Date of Birth (required)
Phone - Home
Phone - Mobile (required)
Father's Name
Mother's Name
Siblings
Health Fund Details
Name of Family Doctor
School / Preschool Child Attends
Days at Preschool
Today's Date

MEDICAL HISTORY

Pregnancy / Birth: Normal DeliveryCaesarian
Details: Breast FedBottle Fed
Transition to Solids: < 3 Months3-6 months6-9 Months9-12 Months> 12 Months
Does your child have difficulties with attention and concentration? YESNO
How often does your child have a cold? OftenSeldomNever
Has your child had many ear infections? YESNO
Has your child had a hearing test? YESNO
Further Details
Is your child currently on any medication? YESNO
Details

Motor Development:

At what age did your child sit?
At what age did your child crawl?
At what age did your child walk?
Details

Has your child been seen by other health professionals?

Occupational Therapist: YESNO
Details
Psychologist: YESNO
Details
Paediatrician: YESNO
Details
Physiotherapist: YESNO
Details
ENT: YESNO
Details
Describe in your own words your child's difficulties
Has anyone else in the family ever had a speech / language / literacy / learning difficulty? YESNO
Details
Has your child received speech pathology services in the past? YESNO
Details
Did your child babble regularly as a baby? YESNO
Details
At what age did your child say their first words?
Did your child keep adding words once they started to talk? YESNO
At what age did your child make small sentences such as "want drink" or "me go"?
Do you feel that your child is able to follow directions?
Does your child repeat sounds, words or phrases when speaking? YESNO

Thank you for taking the time to complete this form. Please do not hesitate to discuss any aspect of this information with me in further detail.

Heidi Rees - Speech Pathologist